formato historia clinica

HISTORIA CLÍNICA Paciente de la cama no._____  Ficha Clínica

Nombre:_____________________________________________________________   _________  Edad:________________ Edad:______________ __ Sexo: ________________ _____________ ___ Estado civil:  ________________  Ocupación:___________________________________________________________   _________  Lugar de Nacimiento:________________ Lugar de Origen: :________________ Religión:____  Motivo de la consulta ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________________ Principio y Evolución del padecimiento actual (PEPA)

Orden cronológico  Tiempo previo a su ingreso  _________________________________   ___   _________________________________   ___ 

Signos y síntomas que se presentaron  _________________________________   ___   _________________________________   ___   _________________________________   ___   _________________________________   ___   _________________________________   ___   _________________________________   ___   _________________________________   ___   _________________________________   ___ 

Redacción  ______________________________________________________________________   _______   ______________________________________________________________________ 

 _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______  Exploración física  ______________________________________________________________________   ______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________ 

 _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________ 

 ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   _________________________________________________  Antecedentes Heredo Familiares

Abuelos _____________________________________________________ ______

Padres _____________________________________________________ ______

 Tíos _____________________________________________________ ______

Primos _____________________________________________________ ______

Hermanos _____________________________________________________ ______

Sobrinos _____________________________________________________ ______

Esposo(a)/p areja _____________________________________________________ ______

Hijos _____________________________________________________ ______

Nietos _____________________________________________________ ______

Antecedentes personales no patológicos

Medio: Urbano Rural Vivienda: Propia Rentada Prestada   Tipo de piso Tierra Cemento Vitropiso Servicios: Agua Luz Drenaje Letrina Fecalismo aire libre Cocina con gas Cocina leña Otros:__________________________  Animales:____________________________________________________________   _________  Fauna nociva:_______________________________________________________________   __  Actividad física (Tipo, duración, frecuencia)  ______________________________________________________________________   _______  Alimentación (Menu que consume regularmente)  ______________________________________________________________________   _______   ______________________________________________________________________   _______   ______________________________________________________________________   _______  Escolaridad:___________________  Higiene:_________________________________________  Inmunizaciones:______________________________________________________   __________   Toxicomanias:_______________________________________________________   __________  Preferencia sexual (numero de parejas)_____________________________________________  Antecedentes gineco-obstetricos gineco-obstetricos

Gesta:________ Partos:________ Abortos:________ Cesareas (mot):______________  Menarca________  FUM:____________ Ritmo:____________ FUP:____________  IVSA:____________  DOC:____________  Uso de anticonceptivos (Tipo y desde cuando se utiliza)  ______________________________________________________________________   _______  Antecedentes personales patológicos patológicos

Quirúrgicos___________________________________________________________   _________   ______________________________________________________________________   _______ 

 Transfusionales (Motivo, numero de unidades):_______________________________________   ______________________________________________________________________   _______   Traumaticos:  __________________________________________________________________   ______________________________________________________________________   _______  Hospitalizaciones:  ______________________________________________________________   ______________________________________________________________________   _______  Infeccioso (tuberculosis, sífilis, hepatitis, faringoamigdalitis, etc):  _________________________   ______________________________________________________________________   _______  Endocrinos:  ___________________________________________________________________   ______________________________________________________________________   _______  Neoplásicos:__________________________________________________________   ______________________________________________________________________   ________________  Cardiovasculares:_____________________________________________________   ______________________________________________________________________   _________________Respiratorios:  __________________________________________________________________   ______________________________________________________________________   _______  Neurológicos:  __________________________________________________________________   ______________________________________________________________________   _______  Hematologicos:_______________________________________________________   __________   ______________________________________________________________________   _______  Psiquiatricos:_________________________________________________________   __________   ______________________________________________________________________   _______  Alérgicos:_____________________________________________________________   ______________________________________________________________________   _______________  Renales:______________________________________________________________   ______________________________________________________________________   _______________  Enfermedades de infancia:  _______________________________________________________ 

 ______________________________________________________________________   _______  Gastrointestinales:  ______________________________________________________________   ______________________________________________________________________   _______  Reumatológicas:  _______________________________________________________________   ______________________________________________________________________   _______  Dermatológicas:______________________________________________________   ______________________________________________________________________   _________________  Interrogatorio por aparatos y sistemas

Síntomas generales (fiebre, pérdida de peso, astenia, anorexia)  ______________________________________________________________________   ______________________________________________________________________   ______________  Dermatologicos  ______________________________________________________________________   ______________________________________________________________________   ______________  Ojos  ______________________________________________________________________   ______________________________________________________________________   ______________  Nariz y garganta  ______________________________________________________________________   ______________________________________________________________________   ______________  Dental  ______________________________________________________________________   ______________________________________________________________________   ______________  Mama  ______________________________________________________________________   ______________________________________________________________________   ______________  Respiratorio  ______________________________________________________________________   ______________________________________________________________________   ______________  Cardiovascular  ______________________________________________________________________   ______________________________________________________________________   ______________  Gasrtointestinal  ______________________________________________________________________   ______________________________________________________________________ 

 ______________  Urinario  ______________________________________________________________________   ______________________________________________________________________   ______________  Genital masculino  ______________________________________________________________________   ______________________________________________________________________   ______________  Genital femenino  ______________________________________________________________________   ______________________________________________________________________   ______________  Sexualidad  ______________________________________________________________________   ______________________________________________________________________   ______________  Músculo esqueletico  ______________________________________________________________________   ______________________________________________________________________   ______________  Reumatologia  ______________________________________________________________________   ______________________________________________________________________   ______________  Hematologia  ______________________________________________________________________   ______________________________________________________________________   ______________  Endocrinología  ______________________________________________________________________   ______________________________________________________________________   ______________  SN  ______________________________________________________________________   ______________________________________________________________________   ______________ 

Exploracion General

 ______________________________________________________________________   ______________________________________________________________________   ______________   ______________________________________________________________________   ______________________________________________________________________   ______________ 

 ______________________________________________________________________   ______________________________________________________________________   ______________   ______________________________________________________________________   ______________________________________________________________________   ______________   ______________________________________________________________________   ______________________________________________________________________   ______________   ______________________________________________________________________   ______________________________________________________________________   ______________